Basic Information
| Provider Information | |||||||||
| NPI: | 1235568171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTES | ||||||||
| FirstName: | PHILOMENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4404 QUEENSBURY RD | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207371068 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 EAST AVE | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017220081 | ||||||||
| FaxNumber: | 4013120318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2013 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R181327 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.